Why have we made neglect so difficult?

1. Why have we made neglect so difficult? Julie Taylor [PhD; RN; MSc; BSc (Hons); RNT; FRCN] Professor of Child Protection

4. Why neglect? • Transformational change is needed in the UK to the way services are provided to children who are vulnerable to neglect. • Neglect is one of the most damaging childhood experiences and is associated with some of the poorest behavioural, emotional and cognitive outcomes. • These affect life chances and contribute significantly to widening social, economic and health inequalities. • Child neglect is a major crisis that requires a comprehensive solution.

5. Suffolk LSCB Neglect Strategy • Priority 2019 • 4/2017 – 3/2018: 13% MASH contacts • Neglect a factor in 31% assessments (nationally 52%) • Average 191 neglect referrals per month • 60% children on a CP plan for neglect • 347 police investigations since 2016 (6 charges) • Last three SCRs: neglect

6. Outcomes for children We know that children who are neglected have some of the poorest emotional and cognitive outcomes, are at high risk of accidents and are vulnerable to sexual abuse.

7. What is the problem? • We have lots of evidence about the causes of neglect. • We have lots of evidence about the effects of neglect on children’s development in the short and long term. • We have quite a bit of evidence about what is needed for effective intervention. • But we seem to struggle to find a way to put what we already know into policy and practice.

8. Definitions • In literature there is a range of definitions: • developmental researchers focus on need and use broad definitions • researchers into the ‘system’ use narrower ones. • Policy has tended to focus on unmet need and early intervention. • Practice is driven by tighter operational definitions.

9. This is an unhappy group of children, presenting the least positive and most negative affect of all groups… These same children were also the most dependent and demonstrated the lowest ego control in the preschool and in general did not have the skills necessary to cope with the various situations. Minnesota Longitudinal Study ‘75 -> (Egeland, Sroufe & Erickson, 1983, p.469)

10. Working Together 2013 Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: • provide adequate food, clothing and shelter (including exclusion from home or abandonment); • protect a child from physical and emotional harm or danger; • ensure adequate supervision (including the use of inadequate care-givers); or • ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs. Working Together 2018

11. … in reality, neglect is what the school teacher, physician, social worker, judge, psychologist, or police officer “say it is” at the time of the report...one should not get hung up on the definition of child neglect but rather get on with helping these children, who are being cared for in a manner far below our society’s accepted standards. Helfer, 1987

12. Young people’s views of neglect • It’s not enough love • My parents not spending time with me • Having to look after your brothers and sisters • Not getting helped with homework • My parents neglecting themselves • Having messy hair and clothes , getting judged for my appearance. • My parents having no control • “Love is a doing word”

13. I used to love school…

14. What does neglect feel like? • Putting up a pretence • Covering up my feelings • Having no friends • Other kids not realising how hard it is • Losing focus at school and then getting told off • Getting the mickey taken out of you, but I blamed myself not my parents “I didn’t think much about it at the time but when I look back I think it shouldn’t have happened”

15. I love going to school - it is my favourite place in the world…

16. Where is my mammy?

17. How many children are currently experiencing neglect in the UK? • It depends what we mean by neglect. • It is relatively easy to find out about the tip of the iceberg. • In recent reviews neglect is the most common reason for children being made subject to a child protection plans 42-49% • Radford et. al (2000) suggest 1 in 10.

18. DfE: Research Questions • What is known about the ways in which children and families directly and indirectly signal their need for help? • To what extent are practitioners equipped to recognise and respond to the indications that a child’s needs are likely to be, or are being neglected, whatever the cause? • Does the evidence suggest that professional response could be swifter?

19. Noticing • Noticing (‘recognition’) is not that complicated. • Health visitors and teachers are perfectly well able to spot children who may be neglected. • They also see it very much as part of their job. They do not need to be persuaded of the importance.

20. Noticing • Around 80% of health and education professionals have encountered neglected children. • Professionals across the board are increasingly aware of such children and of their responsibilities to these children. • Their concerns are about how best to respond – especially when parents do accept the concerns.

21. Helping is more complicated • Helping (‘response’) tends to mean ‘referral’ for universal services and ‘investigation and evidence-gathering’ for children’s social care and police. • Problem at the interface between universal and statutory ‘protection’ services, especially when parents do not accept the concerns.

22. What is known about the ways in which children and families directly signal their need for help? • Very little evidence - most start with substantiated neglect • Mothers could express concerns about potential neglect and parents who misuse substances could identify impact upon their children. • Children don’t directly ask for help; some school nurses in Finland noticed children who sought advice; neglected children could be identified on a self-report computer programme.

23. What is known about the ways in which parents indirectly signal their need for help? • Much more evidence – many familiar parental factors • Studies vary in whether prospective or retrospective and what factors are controlled for. • No certain, clear and predictable pathways emerge. • Nonetheless, all should be noticeable to practitioners as signs of possible need for support.

24. What is known about the ways in which children indirectly signal their need for help? • Internalising and externalising behaviour can be seen by age 3; peer problems by 6; behaviour problems, impaired socialisation and problems with daily living skills by 8 • An example of indirect signs came from two studies of burns which showed, although the burns were similar to those attributable to accidents, it was more likely that: • the child had not been given first aid at the time, • there was a delay of over 24 hours before seeking help. • the burns would be deeper • children fared worse than abused children in keeping appointments and receiving adequate wound care.

25. To what extent are practitioners equipped to recognise and respond to the indications that a child’s needs are likely to be, or are being neglected? • Professionals tend to have higher thresholds than the general public. • Health visitors are very well equipped to recognise parental characteristics and developmental signs in children. • Some examples of good practice e.g. Finland - ‘active and firm’ school nurses. • Absence of evidence about schools, teachers and the police.

26. Does the evidence suggest that professional response could be swifter? • Protocols and guidelines are not a sufficient spur. • Trust, relationships, communication, anxiety, fear and confidence affect willingness to act on concerns. • Many studies referred to the importance of training as a mechanism to raise awareness. • Training when coupled with access to on-going consultation and support could increase recognition and referral of child abuse and neglect • ‏

28. Findings • Deprivational neglect • Medical neglect • Accidents with some elements of forewarning • Unexplained infant deaths in a context of neglectful care and hazardous home environment • Neglect in combination with physical abuse • Suicide among young people

30. Issues in case management over time • Important problems not addressed and neglect marginalised • Lack of therapeutic help • Lack of follow through • Giving parents too many chances • Lack of parental engagement • Inappropriate case closure • Lack of recorded monitoring • Limited response to referrals about risk • Awaiting a trigger before intervening

31. What is the problem? • We have lots of evidence about the causes of neglect. • We have lots of evidence about the effects of neglect on children’s development in the short and long term. • We have quite a bit of evidence about what is needed for effective intervention. • But we seem to struggle to find a way to put what we already know into policy and practice.

34. Challenges of neglect for practitioners • Interaction of structural disadvantage with individual parental circumstances and characteristics • Professional and personal values and thresholds about what constitutes good enough parenting and good enough developmental progress • Bureaucratic structures which mitigate against flexible, tailored responses to individual children • Professional paralysis in the face of what appears to be intractable and overwhelming circumstances - neglect can challenge practitioner’s sense of self efficacy

35. Identifying and managing risk Child protection depends on the knowledge, skills and confidence of those who work with children and families. Staff must be able to manage risk and deal with the complex and highly uncertain environments. (National Guidance for Child Protection in Scotland 2010). No system can fully eliminate risk. Understanding risk involves judgment and balance. To manage risks, social workers and other practitioners should make decisions with the best interests of the child in mind, informed by the evidence available and underpinned by knowledge of child development (Working Together 2018).

36. Thresholds The issue of ‘thresholds’ seems to be associated with confusion about whether the focus should be on: • the severity of the neglect and associated harm to the child or • the likelihood of the parents being able to accept help and make changes without the need for compulsory measures. Understanding and assessing willingness and ability to change is therefore crucial, especially within the speedy timescales of early development.

37. What is the problem…? It is my business if I drink and smoke a bit of stuff now and again…

38. Parents who are ‘hard to reach’

39. My wife and I are getting very tired of people calling round to ask us questions and to see Wasim…

40. What is a public health approach to neglect?

41. A public health approach requires an understanding of: Classification, diagnosis, prevalence and incidence Aetiological research – risk and protective factors, causal mechanisms, and outcomes Intervention and evaluation research – what works for whom in what settings Effectiveness of implementation and dissemination efforts

44. A framework for promotion and prevention Prevention before occurrence Prevention of recurrence Tertiary Prevention’ Long term outcomes Neglect Prevention of impairment Universal Primary Prevention’ Targeted Secondary Prevention

45. Possible Points of Intervention (A Public Health Approach?) Social inequalities Institutional power Neighbour- hood Risk indicators Morbidity & Injury Mortality Educational initiatives Lobbying Parenting support Risk reduction programmes Trauma recovery programmes Poverty, housing Community based primary prevention Downstream (tertiary intervention) Upstream (primary protection) Midstream (secondary prevention)

46. Swine flu Success is a non-event…..

47. STIR HARD: A structured framework for addressing neglect

48. Steps in assessment • Assessment of parents’ functioning including an assessment of their interaction and relationship with their child(ren). • Specification of targets for change that should include the unique problems facing the family. • Implementation of interventions that addresses all aspects of family functioning with goals tailored to address specific areas of family functioning. • Objective measures of changes over time including standardised tests pre- and post-intervention and evaluation of parents’ willingness to change.

49. Extent and type of neglect (Hodson 2018) Safety • How safe is the child’s environment? • What are the arrangements when a child is left? Physical care • Nutrition • Housing • Clothing • Hygiene • Health

50. Cont… Emotional care • Responsiveness • Mutual engagement Developmental care • Stimulation • Approval • Disapproval • Acceptance